Vaccines have disabled many childhood killers of the past and are poised to take out a number of less deadly diseases we have so far endured. But despite their availability, a new survey of states indicates that a million or more kids are not receiving new vaccines, because neither their insurance companies nor states will pick up the tab.

Researchers report that 10 states between 2004 and early 2006 changed their rules to limit public purchases of selected vaccines for residents whose insurance policies do not cover vaccines and often carry high deductibles. The shift forces the underinsured to pony up as much as $89 per dose for a surging array of new and costly vaccines—or simply skip the injections given to prevent potentially fatal childhood diseases including meningitis and pneumonia.

"It's like sending someone to the ER and them getting turned away—you can't imagine these kids not getting vaccine," says Grace M. Lee, assistant professor of pediatrics at Harvard Medical School and Children's Hospital Boston, lead author of the study published in JAMA The Journal of the American Medical Association. "This is really concerning to us because we see the public health sector as a safety net for all underinsured kids."

Lee and colleagues from Harvard Medical School, the Centers for Disease Control and Prevention (CDC) and the Association of Immunization Managers conducted phone interviews and phone or written surveys of state immunization managers from November 2005 to June 2006 to determine their policies on administering the five vaccines—for the bacteria meningococcus and pneumococcus, the viruses hepatitis A and varicella (chicken pox) as well as a booster for adolescents against tetanus, diphtheria and acellular pertussis (whooping cough) called Tdap—most recently recommended by a CDC advisory panel when the study began.

The team discovered that public health departments in 17 states did not inoculate the underinsured against meningococcal bacteria, which can cause potentially fatal meningitis and meningococcemia (a blood infection). The CDC's Advisory Committee on Immunization Practices (ACIP) in February 2005 recommended adding the vaccine to the required cadre of childhood immunizations.

Eight states reported they did not have the funds to vaccinate underinsured kids against pneumococcus; five states said they lacked funds to provide hepatitis A vaccines and two states did not supply varicella vaccine or Tdap.

The ACIP has recommended seven new vaccines in the past dozen years, hiking the cost of completely immunizing a child or adolescent from $155 in 1995 to a hefty $1,170 in 2007, the group notes. Last year's additions were rotavirus, which causes severe but treatable diarrhea, and human papillomavirus, the source of 70 percent of cervical cancer.

The federal government offers free shots to the uninsured and underinsured through an entitlement program called Vaccines for Children, but there's a catch: some underinsured families may have to travel as much as 200 miles to such centers, Lee says, which makes them inaccessible to those who do not have the time, money or transportation to get there.

Section 317 of the Public Health Services Act for the past 30 years has provided federal funds to states for vaccines for the needy, but the funding has not risen with the introduction of new vaccines. Surveyed immunization managers cited a lack of 317 funding as a barrier to coverage in 81 to 100 percent of ineligible children, depending on the vaccine.

"Public health departments have faced substantial stress from what is really something great—new vaccines and new vaccine technologies," says Walter Orenstein, associate director of the Emory Vaccine Center in Atlanta.

Diseases that can be prevented by vaccines claim the lives of 300 U.S. children every year, according to the 317 Coalition, a group funded by the pharmaceutical industry that lobbies Congress for greater vaccine funding.

Prior studies have found that up to 14 percent of children as of 2000 were underinsured, and based on that number, Lee's group estimates that up to 1.2 million may not be receiving all of the recommended vaccines.

Lee says boosting coverage would likely require persuading private health insurance plans to pay for preventive care as well as beefing up the public safety net.

Most of the new vaccines are for disease such as rotavirus that are hobbling but not major killers in the U.S. Still, people may increasingly come to expect them in much the way they came to expect the measles vaccine in the 1970s and 1980s, Orenstein says. Put it this way, he notes: "I would want my children vaccinated against them."

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